2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The Role of the Perceived Neighborhood Social Environment on Adolescent Sedentary Behavior and Physical Activity: Findings from Add Health

Few studies have examined the role of perceived neighborhood characteristics such as neighborhood safety, social cohesion, and contentedness on sedentary behavior (SB) and physical activity (PA) among adolescents. Furthermore, no studies have investigated how these associations are moderated by gender and race. This study aimed to examine the associations of the perceived neighborhood social environment with (SB) and moderate-to-vigorous physical activity (MVPA). Data from 6504 adolescents (aged 15.4 ± 0.03 years) who participated in the National Longitudinal Study of Adolescent Health was used. SB and PA were considered continuously and dichotomously. PNSE variables include safety, social cohesion, and contentedness, where higher values of PNSE indicate a more favorable neighborhood perception. Weighted linear and logistic regression models were used to examine the association of PNSE with continuous total SB (hours/week) and MVPA (bouts/week), and binary excessive SB (14 h/week) and meeting MVPA guidelines (≥ 5 bouts/week), respectively. Associations were stratified by gender and race to test moderation effects. Models were adjusted for demographic, health, parental, and neighborhood covariates. This study found that neighborhood safety and contentedness were negatively associated with SB, whereas neighborhood social cohesion and contentedness were positively associated with PA. Gender-specific and race-specific results remained somewhat consistent with overall findings; however, neighborhood safety was not associated with SB among female and non-White adolescents, respectively. Similarly, neighborhood safety and contentedness were not associated with MVPA for non-White adolescents. Findings suggest that an adolescent's neighborhood environment, gender, and race should be considered when implementing strategies to reduce SB and increase PA.

Dietary fat quality, plasma atherogenic lipoproteins, and atherosclerotic cardiovascular disease: An overview of the rationale for dietary recommendations for fat intake

The scientific evidence supporting the current dietary recommendations for fat quality keeps accumulating; however, a paradoxical distrust has taken root among many researchers, clinicians, and in parts of the general public. One explanation for this distrust may relate to an incomplete overview of the totality of the evidence for the link between fat quality as a dietary exposure, and health outcomes such as atherosclerotic cardiovascular disease (ASCVD). Therefore, the main aim of the present narrative review was to provide a comprehensive overview of the rationale for dietary recommendations for fat intake, limiting our discussion to ASCVD as outcome. Herein, we provide a core framework - a causal model - that can help us understand the evidence that has accumulated to date, and that can help us understand new evidence that may become available in the future. The causal model for fat quality and ASCVD is comprised of three key research questions (RQs), each of which determine which scientific methods are most appropriate to use, and thereby which lines of evidence that should feed into the causal model. First, we discuss the link between low-density lipoprotein (LDL) particles and ASCVD (RQ1); we draw especially on evidence from genetic studies, randomized controlled trials (RCTs), epidemiology, and mechanistic studies. Second, we explain the link between dietary fat quality and LDL particles (RQ2); we draw especially on metabolic ward studies, controlled trials (randomized and non-randomized), and mechanistic studies. Third, we explain the link between dietary fat quality, LDL particles, and ASCVD (RQ3); we draw especially on RCTs in animals and humans, epidemiology, population-based changes, and experiments of nature. Additionally, the distrust over dietary recommendations for fat quality may partly relate to an unclear understanding of the scientific method, especially as applied in nutrition research, including the process of developing dietary guidelines. We therefore also aimed to clarify this process. We discuss how we assess causality in nutrition research, and how we progress from scientific evidence to providing dietary recommendations.

Cardiovascular Risk in Childhood is Associated With Carotid Intima-Media Thickness and Stiffness in Adolescents and Young Adults: The KiGGS Cohort

PURPOSE

Cardiovascular risk factors are widespread among children and adolescents and may lead to accelerated vascular aging in middle adulthood. However, data are scarce on shorter-term consequences, for example, on associated distinctive vascular properties before age 30 years. This study analyzes the association of childhood exposure to cardiovascular risk factors with carotid properties in adolescents and young adults.

METHODS

Four thousand thirty one participants from the population-based German Health Interview and Examination Survey for Children and Adolescents cohort (aged 3-17 years) had carotid intima-media thickness (CIMT) and distensibility coefficient (DC) measurements at the second follow-up (aged 14-28 years). The assessment of cardiovascular risk factors at baseline included information about arterial hypertension, obesity, dyslipidemia, and passive smoking.

RESULTS

Single risk factors and the exposure to multiple cardiovascular risk factors were associated with elevated CIMT and decreased DC. Relative risks for CIMT ≥ 90th centile and/or DC ≤ 10th centile were increased in participants exposed to two (RRCIMT = 1.45 [95% confidence interval 1.11-1.91], p < .05; RRDC = 1.37 [1.02-1.84], p < .05) and ≥ three risk factors (RRCIMT = 1.66 [1.05-2.62], p < .05; RRDC = 1.25 [0.71-2.21], p > .05).

DISCUSSION

Exposure to multiple cardiovascular risk factors starting in childhood is associated with measurably increased CIMT and carotid stiffness in late adolescence and early adulthood. These findings underline the importance of population-wide preventive measures to promote optimal cardiovascular health.

Effects of "Football and Nutrition for Health" program on body composition, physical fitness, eating behaviours, nutritional knowledge, and psychological status among 7 to 10 years school children

Introduction

Noncommunicable diseases and obesity are between the major health threat due to consumption of unhealthy foods and limited time spent on physical activities, a situation of particular concern among children. Since children spend most of their time at school, this study intends to investigate the effect of a school intervention program, which combines recreational football and nutrition education, on body composition, physical fitness, physical activity, blood pressure and heart rate, eating behaviours, nutritional knowledge, and psychological status in elementary school children.

Methods

A total of 67 children, between 7 and 10 years old, were allocated into three groups: the Football Group (FG) which held 2 weekly sessions of 60 min of recreational football, the Nutrition and Football Group (NFG) which held 2 sessions per week of 60 min of recreational football plus 60 min of nutritional education and the Control Group (CG) which maintained its usual curriculum. The intervention lasted 12 weeks. All measurements were collected before and after the intervention.

Results

Intervention groups significantly (p < 0.05) improved BMI Z-score, rest heart rate, horizontal jump and shuttle test, physical activity level, and psychosocial health. The NFG group significantly decreased (p < 0.05) waist-to-height ratio and blood pressure, and significantly increased (p < 0.05) nutritional knowledge, fruit, and fish consumption. While FG significantly decreased (p < 0.05) the percentage of fat mass and significantly increased (p < 0.05) muscle mass and performance in the 20 m sprint.

Discussion

The results have shown to improve nutritional status, explosive strength, aerobic and neuromuscular fitness, as well as increase the level of physical activity. The nutritional education sessions contributed to increase nutritional knowledge and to improve the consumption of healthy food groups in a ludic-educational way. The "Football and Nutrition for Health" program was able to induce short-term improvements in several health markers, highlighting the role of the school curriculum in children's health.

Role of the Autism Risk Gene Shank3 in the Development of Atherosclerosis: Insights from Big Data and Mechanistic Analyses

Increased medical attention is needed as the prevalence of autism spectrum disorder (ASD) rises. Both cardiovascular disorder (CVD) and hyperlipidemia are closely associated with adult ASD. Shank3 plays a key genetic role in ASD. We hypothesized that Shank3 contributes to CVD development in young adults with ASD. In this study, we investigated whether Shank3 facilitates the development of atherosclerosis. Using Gene Set Enrichment Analysis software (Version No.: GSEA-4.0.3), we analyzed the data obtained from Shank3 knockout mice (Gene Expression Omnibus database), a human population-based study cohort (from Taiwan's National Health Insurance Research Database), and a Shank3 knockdown cellular model. Shank3 knockout upregulated the expression of genes of cholesterol homeostasis and fatty acid metabolism but downregulated the expression of genes associated with inflammatory responses. Individuals with autism had higher risks of hyperlipidemia (adjusted hazard ratio (aHR): 1.39; p < 0.001), major adverse cardiac events (aHR: 2.67; p < 0.001), and stroke (aHR: 3.55; p < 0.001) than age- and sex-matched individuals without autism did. Shank3 downregulation suppressed tumor necrosis factor-α-induced fatty acid synthase expression; vascular cell adhesion molecule 1 expression; and downstream signaling pathways involving p38, Jun N-terminal kinase, and nuclear factor-κB. Thus, Shank3 may influence the development of early-onset atherosclerosis and CVD in ASD. Furthermore, regulating Shank3 expression may reduce inflammation-related disorders, such as atherosclerosis, by inhibiting tumor necrosis factor-alpha-mediated inflammatory cascades.

Blood-based circulating microRNAs as diagnostic biomarkers for subclinical carotid atherosclerosis: A systematic review and meta-analysis with bioinformatics analysis

BACKGROUND

Atherosclerosis in carotid arteries can remain clinically undetected in its early development until an acute cerebrovascular event such as stroke emerges. Recently, microRNAs (miRNAs) circulating in blood have emerged as potential diagnostic biomarkers, but their performance in detecting subclinical carotid atherosclerosis has yet to be systematically researched.

AIM

To investigate the diagnostic performance of circulating miRNAs in detecting subclinical carotid atherosclerosis.

METHODS

We systematically searched five electronic databases from inception to July 23, 2022. Subclinical carotid atherosclerosis was defined using carotid intima-media thickness (CIMT). Diagnostic accuracy parameters and correlation coefficients were pooled. A gene network visualisation and enrichment bioinformatics analysis were additionally conducted to search for potential target genes and pathway regulations of the miRNAs.

RESULTS

Fifteen studies (15 unique miRNAs) comprising 2542 subjects were identified. Circulating miRNAs had a pooled sensitivity of 85% (95% CI 80%-89%), specificity of 84% (95% CI 78%-88%), positive likelihood ratio of 5.19 (95% CI 3.97-6.80), negative likelihood ratio of 0.18 (95% CI 0.13-0.23), diagnostic odds ratio of 29.48 (95% CI 21.15-41.11), and area under the summary receiver operating characteristic curve of 0.91 (95% CI 0.88-0.93), with a strong correlation to CIMT (pooled coefficient 0.701; 95% CI 0.664-0.731). Bioinformatics analysis revealed a major role of the miRNAs, as shown by their relation with CCND1, KCTD15, SPARC, WWTR1, VEGFA genes, and multiple pathways involved in the pathogenesis of carotid atherosclerosis.

CONCLUSION

Circulating miRNAs had excellent accuracy in detecting subclinical carotid atherosclerosis, suggesting their utilisation as novel diagnostic tools.

Cardiovascular prevention in childhood: a consensus document of the Italian Society of Cardiology Working Group on Congenital Heart Disease and Cardiovascular Prevention in Paediatric Age

Cardiovascular diseases (CVD) may be manifested from a very early age. Genetic and environmental (epigenetic) factors interact to affect development and give rise to an abnormal phenotypical expression of genetic information, although not eliciting changes in the nucleotide sequence of DNA. It has been scientifically proven that increased oxidative stress (OS) caused by disease (overweight, obesity, diabetes), nutritional imbalances, unhealthy lifestyles (smoking, alcohol, substance abuse) in the mother during pregnancy may induce placental dysfunction, intrauterine growth restriction, prematurity, low birth weight, postnatal adiposity rebound, metabolic alterations and consequent onset of traditional cardiovascular risk factors. OS represents the cornerstone in the onset of atherosclerosis and manifestation of CVD following an extended asymptomatic period. OS activates platelets and monocytes eliciting the release of pro-inflammatory, pro-atherogenic and pro-oxidising substances resulting in endothelial dysfunction, decrease in flow-mediated arterial dilatation and increase in carotid intima-media thickness. The prevention of CVD is defined as primordial (aimed at preventing risk factors development), primary (aimed at early identification and treatment of risk factors), secondary (aimed at reducing risk of future events in patients who have already manifested a cardiovascular event), and tertiary (aimed at limiting the complex outcome of disease). Atherosclerosis prevention should be implemented as early as possible. Appropriate screening should be carried out to identify children at high risk who are apparently healthy and implement measures including dietary and lifestyle changes, addition of nutritional supplements and, lastly, pharmacological treatment if risk profiles fail to normalise. Reinstating endothelial function during the reversible stage of atherosclerosis is crucial.

Diet and Food and Nutrition Insecurity and Cardiometabolic Disease

Poor nutrition is the leading cause of poor health, health care spending, and lost productivity in the United States and globally, which acts through cardiometabolic diseases as precursors to cardiovascular disease, cancer, and other conditions. There is great interest in how the social determinants of health (the conditions in which people are born, live, work, develop, and age) impact cardiometabolic disease. Food insecurity is an example of a powerful social determinant of health that impacts health outcomes. Nutrition insecurity, a distinct but related concept to food insecurity, is a direct determinant of health. In this article, we provide an overview of how diet in early life relates to cardiometabolic disease and then continue to focus on the concepts of food insecurity and nutrition insecurity. In the discussions herein we make important distinctions between the concepts of food insecurity and nutrition insecurity and provide a review of their concepts, histories, measurement and assessment devices, trends and prevalence, and links to health and health disparities. The discussions here set the stage for future research and practice to directly address the negative consequences of food and nutrition insecurity.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Diagnostic performance of different anthropometric indices among Iranian adolescents for intima media thickness in early adulthood: A prospective study and literature review

Background

There is debate regarding which anthropometric indices is the most appropriate predictor of cardiovascular disease (CVD) among adolescents. The purpose of this study was to investigate the association of body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) in adolescents with high carotid intima-media thickness (cIMT) in early adulthood, as the surrogate marker of CVD in a cohort study.

Methods

A total of 875 Iranian adolescents (female = 421) aged 10-17 years old were entered the study. The cIMT was measured in early adulthood (20-38 years old) after 18.2 (median) years of follow-up and defined as > 90th percentile for sex and age groups. The gender specific association between a 1-SD increase in each anthropometric measures with high cIMT was examined using multivariate logistic regression analysis adjusted for age, smoking, family history of CVD, systolic blood pressure, total cholesterol, and fasting blood sugar. In the multivariable analysis, the interaction between sex and age groups with anthropometric measures were significant (all p-values < 0.05).

Results

Among males, all anthropometric measures including BMI, WC, WHR, and WHtR were associated with high cIMT; the corresponding odds ratios were 1.43 (1.05-1.94), 1.63 (1.22-2.19), 1.33 (1.03-1.71), and 1.41 (1.07-1.87), respectively. However, after considering the related adulthood anthropometric measurements, the association remained significant for WC 1.48 (1.04-2.10) and WHR [1.28 (0.99-1.66), P = 0.06]. Moreover, among early adolescent boys aged 10-14 years, all of the anthropometric measures were significantly associated with high cIMT in the multivariate analysis that included the related adulthood anthropometric measures. The area under the curve (AUC) for the anthropometric measurements among males ranged from 0.576 for WHtR up to 0.632 for WC, without any superiority between them. Among females, only in linear regression analysis, a significant association were found between the higher value of WC and WHtR with cIMT measurement in adulthood; however, the risk reached to null after considering adult anthropometric measures.

Conclusion

General and central obesity measures were significantly associated with high cIMT only among Iranian male adolescents, the relationship that were more prominent among pre-pubertal males.

Explainable machine learning framework for predicting long-term cardiovascular disease risk among adolescents

Although cardiovascular disease (CVD) is the leading cause of death worldwide, over 80% of it is preventable through early intervention and lifestyle changes. Most cases of CVD are detected in adulthood, but the risk factors leading to CVD begin at a younger age. This research is the first to develop an explainable machine learning (ML)-based framework for long-term CVD risk prediction (low vs. high) among adolescents. This study uses longitudinal data from a nationally representative sample of individuals who participated in the Add Health study. A total of 14,083 participants who completed relevant survey questionnaires and health tests from adolescence to young adulthood were chosen. Four ML classifiers [decision tree (DT), random forest (RF), extreme gradient boosting (XGBoost), and deep neural networks (DNN)] and 36 adolescent predictors are used to predict adulthood CVD risk. While all ML models demonstrated good prediction capability, XGBoost achieved the best performance (AUC-ROC: 84.5% and AUC-PR: 96.9% on testing data). Besides, critical predictors of long-term CVD risk and its impact on risk prediction are obtained using an explainable technique for interpreting ML predictions. The results suggest that ML can be employed to detect adulthood CVD very early in life, and such an approach may facilitate primordial prevention and personalized intervention.

Atherosclerotic Cardiovascular Risk as an Emerging Priority in Pediatrics

Over the last decades, childhood and adolescence have emerged as an important window of opportunity to prevent atherosclerotic cardiovascular disease (ASCVD) later in life. Here, we discuss the underlying advances in the field. First, atherosclerosis development starts as early as childhood. Atherogenesis initiates in the iliac arteries and abdominal aorta and subsequently develops in higher regions of the arterial tree, as has been demonstrated in nonhuman primate studies and human autopsy studies. Obesity, hypertension, hyperlipidemia, and hyperglycemia at a young age can accelerate atherogenesis. Children and adolescents with obesity have a relative risk of ∼ 2.5 for ASCVD mortality later in life, compared to peers with a normal weight. Conversely, early prevention improves long-term cardiovascular outcomes. Second, we review disease-associated factors that add to the traditional risk factors. Various pediatric disorders carry similar or even higher risks of ASCVD than obesity, including chronic inflammatory disorders, organ transplant recipients, familial hypercholesterolemia, endocrine disorders, childhood cancer survivors, chronic kidney diseases, congenital heart diseases, and premature birth, especially after fetal growth restriction. The involved disease-associated factors that fuel atherogenesis are diverse and include inflammation, vascular, and endothelial factors. The diverse and growing list of pediatric groups at risk underscores that cardiovascular risk management has solidly entered the realm of general pediatrics. In a second review in this series, we will, therefore, focus on recent advances in cardiovascular risk assessment and management and their implications for pediatric practice.

The Combined Effect of Birth Weight and Lifestyle on Clustered Cardio-Metabolic Risk Factors in Children and Adolescents: A National School-Based Cross-Sectional Survey

Background: Due to the adverse effects of cardio-metabolic risk factors (CMRFs) in children and adolescents on their current and later life health, and the growing evidence that birth weight and lifestyle have on CMRFs, we aimed to estimate the combined effect of birth weight and lifestyle on clustered CMRFs in children and adolescents. Methods: We enrolled 11,509 participants aged 7–18 years old in a national school-based cross-sectional study in seven provinces in China in 2013. Information on CMRFs was collected through anthropometric measurements and blood sample testing. Information on birth weight, lifestyle and other basic information were investigated through children and adolescents’ as well as parents’ questionnaires. The generalized linear mixed model was applied to estimate the odd ratio (OR) and 95% confidence interval (95% CI) for the associations between CMRFs, clustered CMRFs and birth weight, lifestyle, and the combinations of birth weight and lifestyle. Results: Overall, the prevalence of clustered CMRFs was 3.6% in children and adolescents aged 7–18 years, higher in boys (4.4%) than girls (2.9%). The combination of LBW/ideal lifestyle (OR = 2.00, 95% CI: 1.07–3.72) was associated with higher risk of clustered CMRFs, as well as in adolescents aged 13–18 years and in boys. The combination of HBW/poor lifestyle (OR = 1.74, 95% CI: 1.13–2.68) was related to elevated risk of clustered CMRFs, especially in children aged 7–12 years. Conclusions: CMRFs in Chinese children and adolescents is concerning, ideal lifestyle could weaken the association of birth weight with clustered CMRFs, especially in younger age, indicating that programs to prevent abnormal birth weight or poor lifestyle or both among children and adolescents may reduce CMRFs in China.

Effectiveness of structured interventional strategy for middle-aged adolescence (SISMA-PA) for preventing atherosclerotic risk factors—A study protocol

Background

Atherosclerotic risk starts at an early stage in adolescents and interventions on adolescents’ lifestyles are most important. The pandemic of obesity-related morbidities like atherosclerosis among young adults and atherosclerotic risk factors for middle-aged adolescents in India is known. Yet, there is a lack of cost-effective and integrated intervention programs to treat this important health problem.

Objective

The main objective of this study is to evaluate the effect of a 12-week structured interventional strategy program, containing integrated education and supervised physical activity interventions for middle-aged adolescents.

Methods/design

This will be a school-based pre-experimental one-group pre-post time-series research design. The sample size is estimated to include 154 adolescents of 10^th to 12^th grade; aged 15–17 years will be grouped as a single arm. Data will be collected from July 2021 to January 2022. The intervention duration will be 3 months. The following measures will be evaluated before, during, and after intervention: knowledge, body mass index, level of physical activity, dietary habits, and sedentary activity.

Discussion

We believe that the structured interventional strategy approach which includes education related to atherosclerosis, physical activity, dietary habits, and sedentary activity, and cost-effective physical activity training will be more effective in preventing atherosclerotic-related changes among middle-aged adolescents. Further, this kind of approach may be applied in similar study areas elsewhere in India.

Trial registration

Clinical Trials Registry—India (Registered Number: CTRI/2021/03/032271).

Home food access and children's heart healthy dietary intake at home and child care

Background: About 12 million children under 5 years of age attend early care and education centers (ECEs). Child intake at home can be impacted by food insecurity, which is higher among low income, rural, and racially diverse families. Aim: Determine whether greater access to fruits, vegetables, and snacks at home was associated with heart-healthy diet score at home and at ECEs in preschool-age children, and to determine whether there is a difference in heart-healthy diet score between home and ECEs. Methods: Cross-sectional study involving children (3-to-5-year-old, n  =  88) who attended 16 licensed ECEs across Oklahoma. Caregivers completed the Healthy Home Survey and 3-Dinner Dietary recall to report children's home food access and home dinner dietary intake, respectively. Researchers recorded children's ECE lunch consumption using the Dietary Observation for Child Care. Heart-healthy diet score was derived from composite scores for six variables: consumption of fish, fruits, vegetables, sodium, fiber, and sugary drinks. Results: Home access to total fruits and vegetables (16.2  ±  6.3) outnumbered snacks (5.5  ±  3.0). No difference in composite heart-healthy diet score between ECEs (1.50  ±  0.8) and home (1.27  ±  0.9, P  =  0.0851). Children within neither environment met recommendations for most variables (vegetables [18-24%], fruit [6-10%], fish [5-10%], fiber [1%], sodium [22-39%]). No relationship between home food access variables and the heart-healthy diet scores at home or ECEs. Conclusion: Dietary intake of children at home and ECEs does not meet heart-healthy diet score recommendations. Interventions should support preschool aged children from families that are located rurally, low-income, racial minorities, and whose primary caregivers work outside the home.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Exercise and Carotid Properties in the Young-The KiGGS-2 Study

Background: Carotid intima-media thickness (cIMT) and stiffness (cS) are predictive markers of early vascular aging and atherosclerotic risk. This study assessed, whether exercise has protective effects on carotid structure and function or on vascular risk in the young. Methods: Volume and change of exercise (recreational and organized sports participation) of German adolescents and young adults was assessed within the prospective population-study KiGGS at KiGGS-Wave-1 (2009-2012) and KiGGS-Wave-2 (2014-2017) using standardized self-reporting questionnaires. CIMT and cS were measured by real-time B-mode ultrasound sequences with semi-automated edge-detection and automatic electrocardiogram-gated quality control in 2,893 participants (14-28 years, 49.6% female). A cumulative index for atherosclerotic risk (CV-R) included z-scores of mean arterial pressure, triglycerides, total/HDL-cholesterol-ratio, body mass index, and HbA1c. Results: At KiGGS-Wave-2 cross-sectional CV-R but not cS and cIMT was lower in all exercise-groups compared to "no exercise" (B = -0.73, 95%-CI = -1.26 to 0.19, p = 0.008). Longitudinal volume of exercise was negatively associated with CV-R (B = -0.37, 95%-CI = -0.74 to 0.00, p = 0.048) but not with cS and cIMT. Cross-sectional relative risk of elevated CV-R but not cS and cIMT was lower in all exercise-groups compared to "no exercise" (RR = 0.80, 95%-CI = 0.66 to 0.98, p = 0.033). High exercise volumes were associated with lower relative risk of elevated CV-R (RR = 0.80, 95%-CI = 0.65-0.97, p = 0.021) and cS in tendency but not with cIMT. Conclusions: Increased levels of exercise are associated with a better cardiovascular risk profile in young individuals, but not with cS and cIMT. Our study confirms previous recommendations on exercise in this age group without demonstrating a clear benefit on surrogate markers of vascular health.

Association of childhood obesity phenotypes with early adulthood Carotid Intima-Media Thickness (CIMT): Tehran lipid and glucose study

BACKGROUND AND AIMS

Over the past few years, obesity and metabolic syndrome prevalence among children and adolescence have an increasing trend. This study aims to investigate the association of obesity phenotypes during childhood and adolescence with early adulthood carotid intima-media thickness (CIMT).

METHODS AND RESULTS

Participants were divided into four obesity phenotypes: Metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUNW), metabolically healthy obese (MHO), and metabolically unhealthy obese (MUO). Participants were followed for 18 years. Multivariate-adjusted Risk Ratios (RRs) were calculated for high CIMT (≥95% percentile) incidence. In this cohort study 1220 children and adolescents with the average age of 10.9 ± 4.0 years were included. CIMT values had a significantly increasing trend from MHNW to MUO group (p for trend<0.001). Individuals with normal weight status, even with an unhealthy metabolic profile did not have higher risk of high CIMT. Similarly, Children with obesity but healthy metabolic status was not at higher risk. On the other hand, MUO phenotype during childhood was associated with increased risk of high CIMT in early adulthood (RR = 2.13, 95%CI (1.02-4.48)). This association became insignificant for all obesity phenotypes after adjusting for adulthood BMI.

CONCLUSION

Adulthood CIMT has an increasing trend based on childhood and adolescence obesity phenotypes from MHNW to MUO. Children with MUO phenotype was the only ones that had an increased risk of high CIMT incidence in early adulthood.

Th1/Th2 Balance in Young Subjects: Relationship with Cytokine Levels and Metabolic Profile

Purpose

We aim to identify Th1 and Th2 cell clusters in young subjects, including their clinical and metabolic characteristics and the Th1/Th2 balance.

Patients and Methods

A total of 100 participants were included. The frequencies of Th1 and Th2 cells in peripheral blood were determined by flow cytometry. Serum C-reactive protein was measured using a turbidimetric assay, and insulin levels were quantified with an enzyme-linked immunosorbent assay. Circulating cytokine levels were analyzed using a multiplex system.

Results

A cluster analysis was performed to determine the Th1/Th2 balance in a group of young people, and 3 clusters were formed with the following characteristics: 1) subjects with a higher prevalence of hyperglycemia (38%), dyslipidemia (38–75%), and insulin resistance (50%), as well as a higher percentage of Th1 cells and Th1/Th2 ratio, including elevated IFN-ɣ levels; 2) subjects with a lower prevalence of hyperglycemia (23%) and insulin resistance (15.4%), but a higher prevalence of dyslipidemia (8–85%) with a predominance of Th2 cells, and lower Th1/Th2 ratio; 3) subjects with a lower prevalence of hyperglycemia (6%), insulin resistance (41%), and dyslipidemia (10–63%), as well as a balance of Th1 and Th2 cells and lower Th1/Th2 ratio, including low IFN-ɣ levels. Positive correlations between Th1 cells with IFN-γ, IL-12, and IL-1β and between Th2 cells with IFN-γ, IL-2, and IL-4 were found (p < 0.05). A significant increase in Th1 cells was observed in the presence of hyperglycemia and high LDL-C levels, as well as increased Th2 cells in the absence of abdominal obesity and high blood pressure, including low HDL-C levels. The Th1/Th2 ratio was higher in the group with high cardiometabolic risk (p = 0.03).

Conclusion

Th1/Th2 balance is related to metabolic abnormalities that may occur in young population, and thus the timely identification of different phenotypes may help predict an increased cardiometabolic risk.

Association of childhood metabolic syndrome and metabolic phenotypes with the carotid intima-media thickness (CIMT) in early adulthood: Tehran lipid and glucose study

BACKGROUND

The clinical significance of metabolic syndrome (MetS) during adolescence and its association with adulthood adverse outcomes is a controversial issue. This study aimed to investigate the association of MetS and metabolic phenotypes with a high carotid intima-media thickness (CIMT) in early adulthood.

METHODS

MetS was defined as proposed by Cook, de Ferranti, the National Cholesterol Education Program (NCEP), and the pediatric International Diabetes Federation (IDF). Metabolic phenotypes were defined based on the binary clustering of cardiovascular risk factors. The participants were adolescent's individual selected from a large cohort study and followed for 18.2 years. Multivariate-adjusted odds ratios (ORs) were calculated for a high CIMT incidence (≥95th percentile).

RESULTS

In this study, 862 adolescents (52.3% males), with the mean age of 13.4 ± 2.2 years, were included. The presence of MetS, based on the definitions proposed by Cook (OR = 1.90, 95% CI: 1.01-3.57, P = 0.046) and de Ferranti (OR = 1.74; 95% CI: 1.04-2.90, P = 0.033), was associated with the increased risk of a high CIMT in early adulthood. Metabolic phenotypes, including high waist circumference (WC)/hypertension (HTN), high WC/low high-density lipoprotein-cholesterol (HDL-C), and high triglyceride (TG)/high WC, showed higher risks of a high CIMT. However, these positive associations become insignificant after adjusting for the adulthood BMI, except for the high WC/low HDL-C phenotype (OR = 2.04, 95% CI: 1.02-4.11, P = 0.044).

CONCLUSION

The high WC/low HDL-C phenotype had a better predictive value and could be used as a simpler alternative for MetS to identify adolescents with a higher risk of high CIMT during early adulthood.

Case Studies in Pediatric Lipid Disorders and Their Management

CONTEXT

Identification of modifiable risk factors, including genetic and acquired disorders of lipid and lipoprotein metabolism, is increasingly recognized as an opportunity to prevent premature cardiovascular disease (CVD) in at-risk youth. Pediatric endocrinologists are at the forefront of this emerging public health concern and can be instrumental in beginning early interventions to prevent premature CVD-related events during adulthood.

AIM

In this article, we use informative case presentations to provide practical approaches to the management of pediatric dyslipidemia.

CASES

We present 3 scenarios that are commonly encountered in clinical practice: isolated elevation of low-density lipoprotein cholesterol (LDL-C), combined dyslipidemia, and severe hypertriglyceridemia. Treatment with statin is indicated when the LDL-C is ≥190 mg/dL (4.9 mmol/L) in children ≥10 years of age. For LDL-C levels between 130 and 189 mg/dL (3.4-4.89 mmol/L) despite dietary and lifestyle changes, the presence of additional risk factors and comorbid conditions would favor statin therapy. In the case of combined dyslipidemia, the primary treatment target is LDL-C ≤130 mg/dL (3.4 mmol/L) and the secondary target non-high-density lipoprotein cholesterol <145 mg/dL (3.7 mmol/L). If the triglyceride is ≥400 mg/dL (4.5 mmol/L), prescription omega-3 fatty acids and fibrates are considered. In the case of triglyceride >1000 mg/dL (11.3 mmol/L), dietary fat restriction remains the cornerstone of therapy, even though the landscape of medications is changing.

CONCLUSION

Gene variants, acquired conditions, or both are responsible for dyslipidemia during childhood. Extreme elevations of triglycerides can lead to pancreatitis. Early identification and management of dyslipidemia and cardiovascular risk factors is extremely important.

Effects of a school-based intervention to reduce cardiovascular disease risk factors among secondary school students: A cluster-randomized, controlled trial

BACKGROUND

Cardiovascular diseases (CVDs) are the number cause of death worldwide. In Ghana CVD has been the leading cause of death since 2001. The prevalence of CVD risk factors among adolescents in Ghana has been increasing. This study seeks to develop, implement and evaluate the effects of a behavioral modification intervention program to reduce CVD risk factors among secondary school students in Brong Ahafo, Ghana.

METHODS

A cluster-randomized controlled trial was conducted with schools as clusters over a period of six-months with pre and post intervention evaluations. Participants were public secondary school students (14-19 years) from four schools in Brong Ahafo, Ghana. Students in the intervention group were trained by the researchers whereas those of the control group received no intervention. The intervention included health education and physical activity modules. Follow-up data using same questionnaire were collected within two weeks after the intervention was completed. Intention-to-treat analysis was performed after replacing missing values using the multiple imputation method. The generalized linear mixed model (GLMM) was used to assess the effects of the intervention study.

RESULTS

The GLMM analyses showed the intervention was effective in attaining 0.77(p<0.001), 0.72(p<0.001), 0.47(p<0.001), 0.56(p<0.001), and 0.39(p = 0.045) higher total physical activity, fruits, vegetables, seafood, and water scores respectively for the intervention group over the control group. The intervention was also significant in reducing -0.15(p<0.001),-0.23(p<0.001),-0.50(p<0.001),-0.32(p<0.001),-0.90(p<0.001),-0.87(p<0.001),-0.38(p<0.001), -0.63(p<0.001), -1.63(p<0.001), 0.61(p<0.001), and -1.53(p = 0.005) carbohydrates, fats and oils, fried eggs, fried chicken, carbonated drinks, sugar, sweet snacks, salted fish, weight, BMI, and diastolic BP. The odds of quitting alcohol use in the intervention group were 1.06 times more than the control group. There was no significant effect on reducing smoking and systolic BP.

CONCLUSION

There is an urgent need for the intervention program to be integrated into the existing curriculum structure of secondary school schools. Implementing the intervention will allow for longer and more consistent impact on the reduction of CVD risk factors among secondary school students.

Incidence and predictors of progression of carotid atherosclerosis in a low-income Chinese population-a prospective cohort study

OBJECTIVE

More than 200 million individuals have been diagnosed with carotid atherosclerosis (CAS) in China. We aimed to investigate the incidence and potential predictors of CAS progression in a low-income rural area in China.

METHODS

A population-based cohort study was conducted on individuals aged ≥45 years from 2014 to 2019. Multivariable analyses were used to investigate the predictors of carotid plaque (CP) formation, plaque number, and carotid intima-media thickness (CIMT).

RESULTS

A total of 1479 participants were finally enrolled in this study. The incidence rate of CP was 42.9 cases per 1000 person-years, and the progression of median CIMT was 137.50 μm over five years. The risk of CP formation increased 2-fold in participants aged ≥75 years (P = 0.002) compared with those aged 45-54 years. The corresponding risk was 59% higher in participants with hypertension (P = 0.001) and 73% higher in alcohol drinkers (P = 0.006). With each 1- standard deviations (SD) increase in high- and low-density lipoprotein cholesterol levels, the risk of CP occurrence decreased by 16% (P = 0.016) and increased by 29% (P = 0.002), respectively. Participants aged ≥75 years exhibited a 3.3-fold higher risk of having a high number of plaques than those aged 45-54 years (P = 0.014). Moreover, older age and the waist-to-hip ratio were independent predictors of CIMT progression.

CONCLUSIONS

This is the first longitudinal study to explore the incidence and predictors of CAS progression in a low-income rural population in China with a high prevalence of stroke. More detailed and precise strategies for prevention and intervention of CAS progression are necessary, especially in low-income rural areas in China.

Influence of early life risk factors and lifestyle on systemic vascular resistance in later adulthood: the cardiovascular risk in young Finns study

PURPOSE

There are limited data available concerning the effects of lifetime risk factors and lifestyle on systemic hemodynamics, especially on systemic vascular resistance. The purpose of the study was to evaluate how lifetime cardiovascular risk factors (body mass index (BMI), high-density lipoprotein, low-density lipoprotein, triglycerides, systolic blood pressure, blood glucose) and lifestyle factors (vegetable consumption, fruit consumption, smoking and physical activity) predict systemic vascular resistance index (SVRI) and cardiac index (CI) assessed in adulthood.

MATERIALS AND METHODS

Our study cohort comprised 1635 subjects of the Cardiovascular Risk in Young Finns Study followed up for 27 years since baseline (1980; aged 3-18 years, females 54.3%) who had risk factor and lifestyle data available since childhood. Systemic hemodynamics were measured in 2007 (aged 30-45 years) by whole-body impedance cardiography.

RESULTS

In the multivariable regression analysis, independent predictors of the adulthood SVRI were childhood BMI, blood glucose, vegetable consumption, smoking, and physical activity (p ≤ .046 for all). Vegetable consumption, smoking, and physical activity remained significant when adjusted for corresponding adult data (p ≤ .036 for all). For the CI, independent predictors in childhood were BMI, systolic blood pressure, vegetable consumption, and physical activity (p ≤ .044 for all), and the findings remained significant after adjusting for corresponding adult data (p ≤ .046 for all). The number of childhood and adulthood risk factors and unfavourable lifestyle factors was directly associated with the SVRI (p < .001) in adulthood. A reduction in the number of risk factors and unfavourable lifestyle factors or a favourable change in BMI status from childhood to adulthood was associated with a lower SVRI in adulthood (p < .001).

CONCLUSION

Childhood BMI, blood glucose, vegetable consumption, smoking and physical activity independently predict systemic vascular resistance in adulthood. A favourable change in the number of risk factors or BMI from childhood to adulthood was associated with lower vascular resistance in adulthood.

The Timing and Sequence of Cardiovascular Health Decline

INTRODUCTION

Childhood declines in cardiovascular health have been linked to the development of subclinical atherosclerosis; however, less is known about the timing and sequence of the decline of the specific cardiovascular health components. The study objective is to identify the patterns of decline and associations with adulthood subclinical atherosclerosis.

METHODS

Data were pooled from 5 cardiovascular cohorts. Clinical components of cardiovascular health (BMI, blood pressure, cholesterol, and blood glucose) were categorized as ideal or nonideal using American Heart Association definitions. Multitrajectory models simultaneously fitted the probability ideal for each factor. Adjusted associations between trajectory groups and carotid intima-media thickness were modeled. Data were pooled from December 1, 2015 to June 1, 2019; statistical analysis occurred between June 1, 2019 and June 1, 2020.

RESULTS

This study included 9,388 individuals (55% female, 66% White). A total of 5 distinct trajectory groups were created: 1 maintained the ideal levels of all the 4 health factors, 2 had risk onset of a single factor in childhood, 1 had risk onset of multiple factors in childhood, and 1 had risk onset in adulthood. Those with childhood multiple risk onset had 8.1% higher carotid intima-media thickness (95% CI=0.067, 0.095) than those in the ideal group, childhood cholesterol risk onset had 5.9% higher carotid intima-media thickness (95% CI=0.045, 0.072), childhood BMI risk onset had 5.5% higher carotid intima-media thickness (95% CI=0.041, 0.069), and early adulthood multiple risk onset had 2.7% higher carotid intima-media thickness (95% CI=0.013, 0.041).

CONCLUSIONS

Those who lost the ideal status of cardiovascular health in childhood and early adulthood had more subclinical atherosclerosis than those who retained the ideal cardiovascular health across the life course, underscoring the importance of preserving the ideal cardiovascular health beginning in childhood and continued into adulthood.

Development of a stand-alone index for the assessment of diet quality in elementary school-aged children

OBJECTIVE

To develop and evaluate a stand-alone Elementary School-aged Children's Index of Diet Quality (ES-CIDQ).

DESIGN

In this cross-sectional study, children filled in a food frequency questionnaire (FFQ) with twenty-nine multiple-item questions on the consumption of foods, portion sizes and eating frequency and a 5-d food diary. Nutrient intakes were calculated with nutrient analysis software. FFQ questions best reflecting a health-promoting diet with reference to dietary recommendations were identified by correlations, logistic regression modelling and receiver-operating characteristics curve analysis.

SETTING

Southwest and Eastern Finland.

PARTICIPANTS

Healthy elementary school-aged volunteers [n 266, mean (sd) age 9·7 (1·7) years] were recruited between March 2017 and February 2018.

RESULTS

A set of questions was identified from the FFQ that best depicted the children's diet quality as defined in the dietary recommendations. These fifteen questions were scored and formulated into a stand-alone index as a continuous index score (range 0-16·5 points) and a two-category score: good and poor diet quality. The cut-off score of six points for a good diet quality had a sensitivity of 0·60 and a specificity of 0·78. Children with a good diet quality (49·8 % of the children) had higher intakes of protein, dietary fibre, and several vitamins and minerals, and lower intakes of sucrose, total fat, SFA and cholesterol compared to children with a poor diet quality.

CONCLUSIONS

The developed short stand-alone index depicted diet quality as defined in the dietary recommendations. Thus, ES-CIDQ may be used for assessing diet quality in Finnish elementary school-aged children in school health care and nutrition research.

Childhood and Adulthood Passive Smoking and Nonalcoholic Fatty Liver in Midlife: A 31-year Cohort Study

INTRODUCTION

Identifying early life risk factors remains key to the prevention of nonalcoholic fatty liver (hereinafter "fatty liver") in adulthood. However, the longitudinal association of childhood passive smoking with adult fatty liver is not studied. We examined the association of childhood and adulthood passive smoking with fatty liver in midlife.

METHODS

This was a 31-year prospective cohort study of 1,315 participants. Information on childhood passive smoking (parental smoking) was collected in 1980 (aged 3-18 years) and 1983 and adulthood passive smoking in 2001, 2007, and 2011. Fatty liver was determined by ultrasound in 2011 (aged 34-49 years).

RESULTS

The prevalence of fatty liver was 16.3%. Both childhood and adulthood passive smoking were associated with higher risk of fatty liver, adjusting for potential confounders such as age, sex, childhood socioeconomic status, and adulthood physical activity and alcohol consumption (relative risk = 1.41, 95% confidence interval: 1.01-1.97 for childhood; 1.35, 1.01-1.82 for adulthood). Individuals with persistent exposure to passive smoking between childhood and adulthood had the highest risk (relative risk = 1.99, 95% confidence interval: 1.14-3.45) compared with those without passive smoking in either childhood or adulthood.

DISCUSSION

Passive smoking in both child and adult lives are associated with increased risk of adult fatty liver, suggesting that the prevention of passive smoking should start as early as possible and maintain throughout lifetime.

Childhood Risk Factors and Adulthood Cardiovascular Disease: A Systematic Review

OBJECTIVE

To conduct a comprehensive review of the literature on childhood risk factors and their associations with adulthood subclinical and clinical cardiovascular disease (CVD).

STUDY DESIGN

A systematic search was performed using the MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases to identify English-language articles published through June 2018. Articles were included if they were longitudinal studies in community-based populations, the primary exposure occurred during childhood, and the primary outcome was either a measure of subclinical CVD or a clinical CVD event occurring in adulthood. Two independent reviewers screened determined whether eligibility criteria were met.

RESULTS

There were 210 articles that met the predefined criteria. The greatest number of publications examined associations of clinical risk factors, including childhood adiposity, blood pressure, and cholesterol, with the development of adult CVD. Few studies examined childhood lifestyle factors including diet quality, physical activity, and tobacco exposure. Domains of risk beyond "traditional" cardiovascular risk factors, such as childhood psychosocial adversity, seemed to have strong published associations with the development of CVD.

CONCLUSIONS

Although the evidence was fairly consistent in direction and magnitude for exposures such as childhood adiposity, hypertension, and hyperlipidemia, significant gaps remain in the understanding of how childhood health and behaviors translate to the risk of adulthood CVD, particularly in lesser studied exposures like glycemic indicators, physical activity, diet quality, very early life course exposure, and population subgroups.

Physical activity is associated with lower pulsatile stress but not carotid stiffness in children

The cardiovascular disease (CVD) process may begin early in life when accompanied by atherosclerotic risk factors. CVD risk factors in children are associated with stiffening of the large elastic arteries, a reflection of subclinical atherosclerosis. Physical activity is a preventative lifestyle strategy that may benefit arterial stiffness by attenuating the hemodynamic stress on the artery wall. This study examined the relations between physical activity, carotid pulsatile stress, and carotid stiffness in children. One hundred and forty children (9-11 yrs; 50.0% male, 57.9% African American, 42.10% Caucasian, body mass index (BMI) 20.1±4.7 kg/m²) participated in this study. Physical activity counts were measured using a wrist-worn accelerometer and averaged over 7 days. Carotid artery β-stiffness and pulse pressure (calibrated to brachial mean and diastolic pressure) were assessed as via ultrasound and tonometry, respectively. Pulsatile stress was calculated as the product of carotid pulse pressure and heart rate. Physical activity counts were correlated with pulsatile stress (r= -0.27), and BMI (r= -0.23), but were unrelated to carotid stiffness. In multivariate models, associations between physical activity counts and pulsatile stress remained (B= -1.3 [95%CI, -2.4, -0.2], β= -0.20, p<0.05) after covariate adjustment for age, race, sex, pubertal stage and BMI. Carotid pulsatile stress was related to regional carotid stiffness (r=0.45, p<0.05). These data suggest that higher levels of physical activity at young age are associated with lower hemodynamic stress in the carotid artery. Findings are discussed in the context of an inverse relationship between hemodynamic pulsatile stress and carotid stiffness in children.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Progress of Clinical Evaluation for Vascular Aging in Humans

Human society is experiencing a serious aging process. Age-related arteriosclerotic cardiovascular diseases (ASCVD) are the most common cause of deaths around the world and bring a huge burden on the whole society. Vascular aging-related pathological alterations of the vasculature play an important role in the pathogenesis of ASCVD and morbidity and mortality of older adults. In this review, we describe the progress of clinical evaluation of vascular aging in humans, including functional evaluation, structural assessment, and cellular molecular markers. The significance of detection for vascular aging is highlighted, and we call for close attention to the evaluation for a better quality of life in the elderly population.

Association Between Pulse Pressure and Carotid Intima-Media Thickness Among Low-Income Adults Aged 45 Years and Older: A Population-Based Cross-Sectional Study in Rural China

Worldwide, the stroke burden remains severe, especially for people in low socioeconomic groups. Atherosclerosis is a leading cause of stroke that is attracting increasingly greater attention. Blood pressure, including pulse pressure (PP) and systolic (SBP) and diastolic (DBP) blood pressures, is a traditional risk factor for atherosclerosis; its association with carotid intima-media thickness (CIMT) has also been widely studied. However, published studies have not reported on the relationship between PP and CIMT in low-income adults. Thus, this study investigated the relationship between PP and CIMT in a low-income population, in China. A total of 3,789 people, aged ≥45 years and without histories of stroke or cardiovascular disease, were recruited into this study. B-mode ultrasonography was performed to determine CIMTs. Demographic characteristics, physical examination data, previous medical histories, and laboratory test results were collected for each study participant. Multiple linear regression models were used to analyze the association between CIMT and PP. The mean CIMT was 567.1 μm (males, 583.5 μm; females, 555.7 μm). The SBP, DBP, PP, and mean arterial pressure (MAP) values were all positively correlated with CIMT, in the univariate analysis; PP and MAP showed the strongest correlations. In addition, in three multiple linear regression models, PP was shown to be significantly associated with CIMT; each 1-mm Hg increase in PP resulted in a CIMT increase of ≥0.41 μm (all P < 0.001). Our results demonstrated that, when compared with SBP, DBP, and MAP, PP may be the best predictor of CIMT. Thus, controlling blood pressure, especially PP levels, is vital to decreasing the prevalence of atherosclerosis, especially in this low socioeconomic status population in China.

Weight Management in Youth with Type 1 Diabetes and Obesity: Challenges and Possible Solutions

PURPOSE OF REVIEW

This review highlights challenges associated with weight management in children and adolescents with type 1 diabetes (T1D). Our purpose is to propose potential solutions to improve weight outcomes in youth with T1D.

RECENT FINDINGS

A common barrier to weight management in T1D is reluctance to engage in exercise for fear of hypoglycemia. Healthcare practitioners generally provide limited guidance for insulin dosing and carbohydrate modifications to maintain stable glycemia during exercise. Adherence to dietary guidelines is associated with improved glycemia; however, youth struggle to meet recommendations. When psychosocial factors are addressed in combination with glucose trends, this often leads to successful T1D management. Newer medications also hold promise to potentially aid in glycemia and weight management, but further research is necessary. Properly addressing physical activity, nutrition, pharmacotherapy, and psychosocial factors while emphasizing weight management may reduce the likelihood of obesity development and its perpetuation in this population.

Circulating Bile Acids Profiles in Obese Children and Adolescents: A Possible Role of Sex, Puberty and Liver Steatosis

Background. Childhood obesity is becoming a major health issue and contributes to increasing the risk of cardiovascular disease in adulthood. Since dysregulated metabolism of bile acids (BAs) plays a role in progression of obesity-related disorders, including steatosis and hypertension, this study aimed to investigate BAs profiles in obese children with and without steatosis and hypertension, as well as exploring the interplay between BAs profile and vascular function. Methods. BAs concentrations were quantified with liquid chromatography-tandem mass spectrometry in 69 overweight/obese children and adolescents (mean age, 11.6 ± 2.5 years; 30 females). Liver steatosis was defined with abdomen ultrasonography, whilst hypertension was defined according to the current European guidelines. Vascular function was assessed with ultrasound technique, by measuring carotid intima media thickness (cIMT) and common carotid artery distensibility (cDC). Results. Total and individual glycine-conjugated BAs concentrations were found to be significantly higher in males compared to females, as well as in pre-pubertal compared to pubertal stage (p < 0.05 for both). No difference in BAs concentration was observed between hypertensive and normotensive subjects. Total BAs and glycine conjugated BAs were significantly higher in participants with steatosis compared to those without (p = 0.004 for both). The values of total glycine-conjugate acids were positively correlated with cDC and this association remained significant in linear regression after adjusting for sex, age, pubertal stage, body mass index and aspartate aminotransferase. Conclusion. The results suggest a possible role of BAs in the pathogenesis of liver and/or vascular damage in children and adolescent. Further studies are hence needed to validate these preliminary findings.

Sex Differences in Longitudinal Determinants of Carotid Intima Medial Thickening With Aging in a Community-Dwelling Population: The Baltimore Longitudinal Study on Aging

Background Common carotid intima medial thickness (IMT) increases with aging. However, the longitudinal association between IMT and other age-associated hemodynamic alterations in men and in women are not fully explored. Methods and Results We analyzed repeated measures of IMT, blood pressure, and carotid-femoral pulse wave velocity over a 20-year period in 1067 men and women of the Baltimore Longitudinal Study on Aging; participants were ages 20 to 92 years at entry and free of overt cardiovascular disease. Linear mixed-effects models were used to calculate the individual rates of change (_Change) of IMT, pulse pressure, mean arterial pressure, and pulse wave velocity, among other covariates. Multivariate regression analysis was used to examine the association of IMT_Change with baseline and rates of change of hemodynamic parameters and cardiovascular risk factors. IMT increased at accelerating rates from 0.02 mm/decade at age 50 years to 0.05 mm/decade at age 80 years greater rates in men than in women. IMT_Change was positively associated with baseline low-density lipoprotein, low-density lipoprotein_Change, and baseline systolic blood pressure and systolic blood pressure_Change, but inversely with baseline diastolic blood pressure and diastolic blood pressure_Change. When blood pressure was expressed as pulse pressure and MAP, IMT_Change was positively associated with baseline pulse pressure and pulse pressure_Change and inversely with baseline mean arterial pressure and mean arterial pressure_Change. In sex-specific analysis, these associations were observed in women, but not in men. Conclusions In summary, our analyses showed that IMT increases at accelerating rates with aging. Age-associated changes in IMT were modulated by concurrent changes of low-density lipoprotein in both sexes, and of pulsatile and mean blood pressure in women but not men.

Instructing Ultrasound-guided Examination Techniques Using a Social Media Smartphone App

Social media applications on smartphones allow for new avenues of instruction in sports medicine and exercise sciences. This study tested the feasibility of instructing health care personnel through videos of ultrasound vascular measurements distributed by a social media messenger application. After two training sessions with an ultrasound device, voluntary physicians (n=10) and nurses (n=10) received a video for the performance of an ultrasound-guided determination of intima-media-thickness and diameter of the femoral arteries via a social media messenger application. All participants examined the same healthy human subject. There was no significant difference between the groups regarding overall time of performance, measurements of the femoral arteries, or a specifically designed "assessment of mobile imparted arterial ultrasound determination" score. The physicians group achieved significantly higher scores in the established "objective structured assessment of ultrasound skills" score (p=0.019). Approval of the setting was high in both groups. Transmission of videos via social media applications can be used for instructions on the performance of ultrasound-guided vascular examinations in sports medicine, even if investigators' performances differ depending on their grade of ultrasound experience. In the future, the chosen approach should be tested in practical scientific examination settings.

Retinal Vessel Analysis as a Novel Screening Tool to Identify Childhood Acute Lymphoblastic Leukemia Survivors at Risk of Cardiovascular Disease

BACKGROUND

Microvascular endothelial dysfunction is central to the pathogenesis of cardiovascular disease (CVD). The eye offers direct access for endothelial health assessment via the retinal microvasculature. The aim of the study was to investigate whether image-based retinal vessel analysis is a feasible method of assessing endothelial health in survivors of childhood acute lymphoblastic leukemia (cALL).

MATERIALS AND METHODS

Cardiovascular risk factors (CRFs) were estimated using the 30-year Framingham Risk Score in 73 childhood leukemia survivors (median age: 25; median years from diagnosis: 19) and 78 healthy controls (median age: 23). Radial arterial stiffness was measured using pulse wave analyzer, while endothelial activation markers were measured by soluble intercellular adhesion molecule 1 (sICAM-1) and soluble vascular cell adhesion molecule 1 (sVCAM-1). Retinal fundus images were analyzed for central retinal artery/vein equivalents (CRAE/CRVE) and arteriolar-venular ratio (AVR).

RESULTS

cALL survivors had higher CRF (P<0.0001), arterial stiffness (P=0.001), and sVCAM-1 (P=0.007) compared with controls. Survivors also had significantly higher CRVE (P=0.021) while AVR was significantly lower (P=0.026) in survivors compared with controls, compatible with endothelial dysfunction. In cALL survivors with intermediate risk for CVD, CRAE, and AVR are significantly lower, while sVCAM-1 and sICAM-1 are significantly higher when compared with survivors with low CVD risk after adjusting with covariates (age, sex, and smoking status).

CONCLUSIONS

cALL survivors have an increased risk of CVD compared with age-matched peers. The survivors demonstrated microvasculopathy, as measured by retinal vascular analysis, in addition to physical and biochemical evidence of endothelial dysfunction. These changes predate other measures of CVD. Retinal vessel analysis may be utilized as a robust screening tool for identifying survivors at increased risk for developing CVD.

Effects of gut microbiome-targeted therapies on cardiometabolic outcomes in children and adolescents: A protocol for systematic review and meta-analysis

BACKGROUND

Emerging evidence indicates the role of gut microbiota in the development of cardiovascular diseases. Thus, gut microbiota is increasingly recognized as a potential therapeutic target of cardiovascular disease. However, the effects of gut microbiome-targeted therapies on cardiometabolic outcomes in children and adolescents remain unclear.

METHODS

We plan to perform a systematic search from PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science. Two authors will independently select the relevant studies and extract data according to a previously defined data extraction sheet. We will use the Stata 14.0 statistical software and RevMan V.5.3 software to conduct data analyses.

RESULTS AND CONCLUSION

The results of this study will be published in a peer-reviewed journal and provide more evidence for the application of gut microbiome-targeted therapies in children and adolescents for the intervention of cardiovascular risk factors in clinical practice.

PROTOCOL REGISTRATION NUMBER

INPLASY202060050.

Cardiovascular risk factors from childhood and midlife physical function: The Bogalusa Heart Study

OBJECTIVES

Life-course models have been infrequently applied to physical function. We sought to examine the effects of the cumulative burden of cardiovascular risk factors (CVRFs) from childhood on physical function in midlife.

METHODS

This longitudinal study consisted of 718 participants (aged 37 to 56 years at follow-up) who were examined for CVRFs at least four times during childhood and at least twice in adulthood, with 39 years of follow-up. We assessed physical function in 2013-2016 with the Short Physical Performance Battery (SPPB), 6-minute walking test (6MWT), and handgrip strength. The area under the growth curve (AUC) was used as a measure of cumulative exposure to CVRFs during childhood.

RESULTS

AUC of HDL-cholesterol levels in childhood were positively associated with SPPB score. AUC levels of body mass index (BMI) and triglycerides (TG) were inversely associated with 6MWT. Higher AUC levels of systolic/diastolic blood pressure (BP) predicted poorer hand grip strength. The number of childhood CVRFs in the top quartile, including AUC levels of BMI and TG, were inversely associated with 6MWT and remained significant after adjustment for the adulthood CVRFs.

CONCLUSION

Cumulative burden of CVRFs from childhood were associated with worse physical function in midlife independent of adulthood CVRFs.

Childhood Obesity and Cardiovascular Disease Risk: Working Toward Solutions

The prevalence of obesity in childhood is high and continues to increase globally. It is currently estimated that 381 million children worldwide have overweight or obesity. This disease stems from multiple complex pathways that can present early in life. This is particularly concerning because childhood obesity is associated with cardiovascular risk factors that can lead to early atherosclerosis and premature cardiovascular disease (CVD). Hypertension, dysglycemia, dyslipidemia, and systemic inflammation are associated with vascular changes in childhood, and these contribute to increased risk of cardiovascular events in adulthood if not adequately treated. Interventions to treat childhood obesity include multicomponent family-based behaviour modification programs, which have been demonstrated to have moderate short-term effects on weight-related outcomes; their effects on cardiovascular risk factors, however, are less well understood. Although supervised, structured exercise interventions result in improvements in blood pressure, inflammation, carotid artery intima media thickness, dysglycemia, dyslipidemia, and endothelial dysfunction in children with obesity in the short term, our understanding of how to translate these interventions into long-term sustainable exercise or physical activity recommendations remains uncertain. Research focus in these areas will help in treating childhood obesity and associated CVD risk factors to prevent CVD development in adulthood.

Evidence Gaps in the Identification and Treatment of Hypertension in Children

The ultimate goal of recognizing and treating hypertension in childhood is to prevent target-organ damage during childhood and to reduce the risk of adulthood cardiovascular disease. The quality of evidence to guide blood pressure management in children is lower than in adult medicine, yet some common findings support clinical practice recommendations. Oscillometric devices are increasingly replacing manual blood pressure measurements, but evidence shows that readings are not equivalent between the 2 methods. In addition, multiple blood pressure readings are needed before diagnosing a child with hypertension, but the optimal number and timing are still being determined. The recent American Academy of Pediatrics blood pressure guideline has revised the normative data tables and included threshold blood pressure limits which seem to identify children with higher cardiovascular risks. Threshold limits vary between guidelines, and the most accurate threshold has yet to be determined. Lifestyle modifications are a cornerstone of hypertension management, but the optimal diet and physical activity changes for beneficial effect are not known. When pharmacotherapy is needed, physicians have used drugs from all antihypertensive classes in children, yet only a few classes have been systematically studied. The long-term cardiovascular consequences of elevated blood pressure during childhood are under investigation and it seems that the lower the childhood blood pressure the better and that the rate of change during childhood is predictive of adulthood disease. With much still to learn, this article summarizes the evidence and the evidence gaps for the diagnosis, investigation, management, and outcomes of pediatric hypertension.

The effectiveness of high-intensity interval training on body composition, cardiorespiratory fitness, and cardiovascular risk factors in children: A protocol for a systematic review

BACKGROUND

No previous systematic review has examined the effect of high-intensity interval training (HIIT) interventions on body composition, cardiometabolic risk factors and cardiorespiratory fitness (CRF) in healthy schoolchildren from 5 to 12 years old.

METHODS

This study will be conducted by following the guideline of the preferred reporting items for systematic review and meta-analysis protocols. An electronic search in MEDLINE (via PubMed), EMBASE (via Scopus), SPORTDiscus, Cochrane Library and Web of Science databases of all dates from inception will be conducted. We will include randomized controlled trials aimed to assess the effectiveness of HIIT to improve cardiometabolic risk factors, body composition, and CRF in children. Two authors will perform the study selection and data collection; disagreements will be solved by a third reviewer. The methodological quality of studies will be assessed by the Cochrane Collaboration's tool for assessing risk of bias (RoB2). Data analysis and synthesis will be performed by Comprehensive Meta-analysis Software and StataSE software, version 15.

CONCLUSION

The results should be disseminated through publication in a peer-reviewed journal. Since the data used in systematic reviews of this type will be extracted exclusively from published studies, approval form and ethics committee will not be required.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Impact of sedentary behavior on large artery structure and function in children and adolescents: a systematic review

Sedentary behavior contributes to increased atherosclerotic risk in adults. Whether or not this can be extended to pediatric populations is unclear. This systematic review assessed associations of sedentary behavior with large artery structure and function in pediatric populations. MEDLINE, EMBASE, CENTRAL, and Web of Science were searched from the earliest available date to 31st of December 2018. Analyses of associations of sedentary behavior with large artery structure or function in a pediatric (sub-)population were included, adhering to the PRISMA guidelines. The protocol was published in advance on PROSPERO (CRD42018112996). Study quality and quality of evidence were analyzed using NHLBI Study Quality assessment tools and GRADE. Six observational studies found no association of exposure and outcome variables, and one had contradicting results. One intervention found reduced flow-mediated dilation after 3 h of uninterrupted sitting. Exposure and outcome measures were highly heterogeneous. Study quality was low to moderate. Quality of evidence was very low or low in the observational studies and high in the intervention.Conclusion: In pediatric populations, current evidence is limited and of low quality about how acute effects of sedentary behavior translate into early vascular aging and the long-term development of vascular dysfunction and atherosclerotic risk. Future studies should emphasize a careful choice of the adequate type and measurement site of a biomarker for large artery structure and function as well as conduct a detailed assessment of sedentary behavior patterns.Trial registration: PROSPERO Registration Number: CRD42018112996What is known: • An independent association of sedentary behavior and biomarkers of large artery structure and function has been demonstrated in adults. • In children, sedentary behavior is directly associated with classical cardiovascular risk factors like elevated blood glucose levels, insulin resistance, high blood pressure, obesity, and elevated blood lipids.What is new: • Currently, only few studies of low quality in children and adolescents provide limited evidence about how acute effects of sedentary behavior translate into early vascular aging and the long-term development of atherosclerosis. • The type and measurement site of vascular biomarker need to be chosen carefully, and a detailed assessment of sedentary behavior patterns is important to minimize the methodological bias.